=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700866324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERROLD A CLARK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2275 NORTHWEST PARKWAY SE SUITE 140
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-9319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-951-1793
-----------------------------------------------------
Fax | 770-612-3380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14275 MIDWAY RD SUITE 400
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-951-1793
-----------------------------------------------------
Fax | 610-271-4245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZB0001X
-----------------------------------------------------
Taxonomy Name | Blood Banking & Transfusion Medicine Physician
-----------------------------------------------------
License Number | 026841
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 026841
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------